736 DISEASES OF THE GALL-DUCTS. 



gall-bladder, as well as attacks of gall-stone colic that have preceded 

 the pain, and, in rare cases, the discovery of a distention and fulness 

 of the gall-bladder by calculi (Oppolzer), may excite the suspicion that 

 the walls of tne gall-bladder are inflamed and ulcerated on account of 

 the concrements in it. If the gall-bladder be perforated before it has 

 become adherent to the surroundings, we have the symptoms so often 

 described, which are almost pathognomonic of the entrance of foreign 

 bodies into the peritonaeum, and, in a few days, the patient dies of 

 diffuse peritonitis. If the neighboring organs have become adherent 

 to the gall-bladder, when this is perforated, the pain is limited to the 

 region of the gall-bladder; besides the above symptoms, there is dis- 

 turbance of the functions of the bowels, and the symptoms of the dis- 

 ease often remain obscure till they are explained by the passage of a 

 calculus, which is so large that it could not possibly have passed the 

 ductus choledochus. Concrements entering the intestines through an 

 abnormal communication between them and the gall-bladder may be 

 so large as to pass through the bowels with difficulty, and may give 

 rise to the symptoms of obstruction of the intestines. I have a choles- 

 terin calculus larger than a pigeon's egg, which was given to me as an 

 intestinal calculus, and which was passed with great pain by a lady, 

 " after repeated attacks of hepatitis." If the inflamed bladder adhere 

 to the anterior wall of the abdomen, we may occasionally feel it as a 

 hard circumscribed tumor; subsequently the abdominal walls them- 

 selves become inflamed, an abscess forms in them, from which pus, bile, 

 and often a great number of gall-stones, may be evacuated. The ab- 

 scess does not always open at the part of the wall lying over the gall- 

 bladder, but occasionally opens at a distance, after fistulous passages 

 have formed in the walls. The fistula rarely closes after one or a few 

 concrements have been evacuated ; it more frequently lasts for a long 

 while or always, constantly or at intervals pouring out bile, and, if 

 the cystic duct be closed, a limpid fluid. 



Inflammation and ulceration of the excretory bile-ducts, caused by 

 calculi, are preceded by the symptoms of gall-stone colic ; but this, 

 instead of terminating, as it might, in complete recovery, leaves pain 

 in the region of the liver, and great sensitiveness to pressure. When 

 the impaction of the calculus, and the consequent inflammation, has 

 affected the ductus choledochus, there is also intense icterus, and other 

 symptoms of excessive biliary obstruction. Far more rarely, from its 

 angular form, the calculus closes the excretory duct incompletely, so 

 that small quantities of bile continue to reach the intestine. In such 

 oases the faeces are not entirely discolored, and the icterus does not 

 become so intense. In this case, also, there may finally be perforation, 

 *jid consequent peritonitis (AndraT). But more frequentlv, the pa- 



